(Of course, we prefer nature’s answer, found in our “3-Step Shingles Protocol” plan. However, there are standards treatments available for shingles.)
The standard treatment of shingles uses two types of drugs:
A. Analgesics (pain relievers), and
B. Antiviral agents, which reflect its two goals.
1. Resolve Pain Rapidly
Severe pain can predispose patients to PHN by permanently sensitizing nerves to even the mildest stimulation. Therefore, aggressive pain relief with paracetamol (codeine plus acetaminophen) is advised; some patients require opioids such as morphine. The goal is to reduce pain to a level compatible with daily activities and to have the patient confirm that the level of relief is satisfactory.
2. Stop Virus Replication
Antiviral drugs stop the virus from reproducing itself, thereby minimizing the damage it does to nerve cells. Three antiviral drugs are currently in use. Acyclovir is the standard and has proven effective in accelerating pain resolution. Valacivclovir has been shown to be about a third faster in resolving pain than acyclovir. Famciclovir does not appear to offer a significant advantage over acyclovir.
Older studies with a limited number of patients have indicated that oral corticosteroids (prednisone, triamcinolone) might decrease the likelihood of PHN. An article in the New England Journal of Medicine reported a slight benefit of these drugs in decreasing the severity of acute herpes zoster, but no long-term effects (Wood et al. 1994).
A 1996 article by Whitley et al. in the Annals of Internal Medicine agreed, but found that oral corticosteroids may benefit quality of life. In general, the side effects of steroid therapy are felt to outweigh the benefits, although it may be considered in patients over 50 who have no contraindications.
The rash may be treated with bland protective creams like zinc oxide. Calamine lotion may provide cooling comfort.
Cimetidine
Herpes simplex outbreaks have been shown to go into remission in response to the proper dose of cimetidine. In cases of herpes zoster (shingles), which targets the older population, cimetidine has been successfully used to lessen the debilitating pain and intensity of the skin rash and eruptions. Published studies indicate that viruses like herpes simplex and herpes zoster can be put into quick remission, or the breakouts prevented altogether, when T-lymphocyte suppressor cell function is inhibited.
The best way of accomplishing this is to take 200 mg of cimetidine (Tagamet), 3 times a day, and then 400 mg at bedtime. Tagamet is available in pharmacies over-the-counter. Suggested use is to initiate Tagamet as soon as symptoms of a herpes-related virus infection appear. Continue to take it for 1-2 weeks after all symptoms of the outbreak have abated.
Various studies support the use of cimetidine in suppressing herpes infections. The first case observation occurred in August 1977, when a patient developed shingles just before commencing a course of cimetidine for a chronic stomach ulcer. The patient experienced dramatic relief of the shingles pain and rapid disappearance of the eruption. On the basis of this observation, cimetidine was prescribed to 21 patients with herpes zoster (shingles). The results were encouraging in 18 of these 21 patients.
The trial was then extended to other herpes virus infections. In six of seven patients with herpes labialis (lip), the blisters were aborted, and in one patient with herpes keratitis (cornea), the result was also encouraging, with the attacks being markedly shortened in duration and reduced in frequency. The results of these preliminary trials showed the potential role of cimetidine in the treatment of herpes virus infection ( Van der Spuy et al. 1980 ).
In 1996, a clinical trial was conducted on 221 patients with herpes zoster who were treated daily with cimetidine at 200 mg, 3 times during the day and 400 mg at night. The results showed that cimetidine shortened the period of disease duration. The authors suggested using cimetidine in the treatment of shingles during the earliest stages of the disease ( Kapinska-Mrowiecka et al. 1996 ).
A case reported in Canada resulted in the statement that cimetidine therapy appeared to reduce the expected length of the active phase of herpes zoster from 35 days or more to just 10 days (Hayne et al. 1983). At the Golda Medical Center in Israel, in 1994, a double-blind, placebo-control study of cimetidine treatment versus placebo was conducted for 1 week in 22 patients with herpes zoster. Those who were treated with cimetidine were found to recover much more quickly from skin rash and pain than those who were given the placebo ( Komlos et al. 1994 ).
At the Department of Neurology at Lady Davis Carmel Hospital in Israel, a randomized study evaluated the effect of cimetidine in the treatment of herpes zoster virus. The conclusion was that cimetidine treatment “shortened the median interval until the first decrease in pain, shortened the median interval until the complete resolution of pain, and promoted faster complete healing of skin lesions” ( Miller et al. 1989 ).
A paper presented by a researcher at Michigan State University in the Department of Pediatrics and Human Development (Kumar 1990) stated:
“Suppressor T lymphocytes possess histamine 2 (H2) receptors and contribute significantly to the function of the immune system. Cimetidine has been shown to enhance a variety of immunologic functions both in vivo and in vitro because of its inhibitory effects on suppressor-cell function. Successful tumor immunotherapy has been reported in experimental animals. Patients who received cimetidine were shown to exhibit enhanced cell-mediated immunity as evaluated by increased response to skin-test antigens, restoration of sensitivity following development of acquired tolerance, and increased responses of lymphocytes to mitogen stimulation. Patients also demonstrated that patients with herpes zoster and herpes simplex who were given cimetidine may have benefitted therapeutically from the drug.”
The consensus from these studies is that when cimetidine is administered to those with herpes simplex or shingles, the result is a dramatic relief of the herpetic pain as well as rapid disappearance of the blisters.
Neuralgia Treatment
Tricyclics
The first line of PHN (postherpetic neuralgia) treatment is tricyclic antidepressants. In PHN, these drugs act as analgesics, not antidepressants. Therapy begins at doses lower than required for antidepressant activity, with stepwise increases. Their mechanism of action is unclear. They block reuptake of monoamine neurotransmitters (norepinephrine and/or serotonin) and may act on descending systems from the brainstem. Amitriptyline (Elavil), which affects both transmitters, is most effective, but nortriptyline, which works only on norepinephrine, has fewer side effects (dry mouth, constipation, drowsiness).
Tricyclics are effective in 60-70% of patients. They decrease the intensity of pain but do not relieve it. Therapy should not end until 3-6 months after pain reduction, and then should be decreased gradually. Some shingles patients, however, may choose to end tricyclic drug therapy early because of unpleasant side effects.
Anticonvulsants and Phenothiazines
Although these drugs have been used for certain types of PHN pain, there has been little research evidence to support their effectiveness. Gabapentin (Neurontin), a structural gamma-aminobutyric acid (GABA) analogue, which is approved as an anticonvulsant, but is chemically unrelated to any other mood-regulating or anticonvulsant medication, has been shown to be efficacious and safe at reducing pain levels in patients with PHN and other disorders (Beydoun 1999; Block 2001; Alper et al. 2002).
In a multicenter double-blind, randomized, placebo-controlled 7-week study, gabapentin was shown to reduce pain scores, and a number of patients reported significant reduction of over 50% in a variety of pain scores. Gabapentin was used in divided doses of 1800 and 2400 mg a day in this study (Rice et al. 2001).
Opioids
Opioids can be used to manage PHN pain, although there is debate over whether PHN pain responds to opioids. Several studies indicate relief from pain for patients using opioids. A study done with controlled-release oxycodone showed it to be an effective analgesic for the type of pain that characterizes postherpetic neuralgia (Watson et al. 1998).
Another study with several modalities of treatment, including opioids, showed that the success of the treatment was dependent upon the history of pain being less than 1 month. The majority of those patients showed good to excellent results, whereas only a third of the patients with a history longer than 6 months had adequate relief. The authors concluded that early and appropriate treatment is desirable for patients who have zoster neuralgias (Wulf et al. 1991). Another study indicated opioids given intravenously can be beneficial for pain (but likely very inconvenient for the patient) (Rowbotham et al. 1991).
Topical Therapies
Topical skin creams offer the benefit of massage as well as direct pain relief. Silvadene, Aspercreme, and capsaicin creams may supply some pain relief, although capsaicin must be used 3 to 4 times a day for several weeks to achieve relief. A benefit of using capsaicin is the lack of drug interactions. Capsaicin has been shown to reduce the pain in PHN patients by as much as 80% in studies from 1987 to present (Bernstein 1987; Bernstein et al. 1987, 1989; Watson et al. 1988; Carmichael 1991; Peikert et al. 1991).
In one study of 17 patients, 11 reported more pain and allodynia after use (Petersen et al. 2000). Wearing light cotton fabric or using plastic “artificial skin” sprays can minimize tactile allodynia caused by clothing. Cold packs applied over a cotton towel may also be helpful.
These therapies that can be useful in any chronic pain syndrome include counseling, cognitive behavior modification, relaxation training, biofeedback, and hypnosis.
Physical Therapies
Physical therapies such as ultrasound, laser therapy, and transcutaneous electrical nerve stimulation (TENS) can be helpful (Robertson et al. 1990). Acupuncture reportedly has proven disappointing. A handheld vibromassager may be just as effective and easier to manage than TENS, especially for elderly patients.
Surgery
A specialist may blockade peripheral nerves or use subcutaneous intravenous injection of a local anesthetic such as lidocaine to control PHN pain.